Ambiguous bioethics messages from high places

The two of the biggest bioethics news items in the media this past week have formal similarities: they first raise interest, and end in puzzlement. First, the words of the Pope. The Catholic church, as is well known, is against the use of contraception, because it is said to sever the natural connection between sexuality and procreation. However, condoms -- when used and used properly -- are very effective at preventing the spread of HIV infection. This is why the Church's principled prohibition against condoms looks sinister in the context of the HIV/AIDS epidemic. It makes the Church look indifferent to (if not complicit in) the spread of HIV infection and the sickness, suffering and death that often accompanies it. Last week, the Pope floated a few ideas around that suggested that the use of condoms could be morally permissible in exceptional circumstances. And his example of such an exceptional circumstance was quite striking:

There may be a basis in the case of some individuals, as perhaps when a male prostitute uses a condom, where this can be a first step in the direction of a moralization, a first assumption of responsibility, on the way toward recovering an awareness that not everything is allowed and that one cannot do whatever one wants.

If the male prostitute is a gay sex worker, then the condom is not being used anti-procreatively, for obvious reasons. Hence, male prostitute condom use is not against Church doctrine -- not that this particular topic has been a rich source of doctrinal debate, to my knowledge. So the exception is not particularly helpful for regions like, say, sub-Saharan Africa, where male prostitutes are not the drivers of the HIV epidemic, God-fearing (and often married) heterosexuals are. And here is where it gets murkier: a Vatican spokesman claimed that the Pope was not talking about the use of condoms among male sex workers alone, but also with any "man, woman or transexual." (Gay sex workers and transexuals: since when did the Vatican get so racy?) The use of condoms could be regarded as a moral act if the intention is to prevent grave risk happening to another person. But is the spokesman really speaking for the Pope? Why were the Pope's comments part of some obscure interview? Is the Pope seriously considering a U-turn on condoms, or just floating something out there, testing the conservative waters?

The secular state has its own ways of being obscure. President Obama ordered a review of the ethics of research sponsored by the US government involving human participants. According to the press release, the review was provoked by the recent revelations that the US government funded and helped to conduct dubious syphilis research in Guatemala in the 1940's. The new (and newly renamed) Presidential Commission for the Study of Bioethics Issues is to lead the review. But, on reflection, this does not make much sense. The scandal in Guatemala happened sixty years ago. In the meantime, we had the infamous Tuskegee syphilis studies, the Belmont Report, the creation of the Common Rule, the proliferation of IRBs, the rise of bioethics centers, programs and scholarly journals, and much more besides. Why would an event which pre-dated all this trigger a review of all this? The only reason I can see is ... that there must have been calls to review the system of ethics protections already, and the news of the Guatemala scandal came at an opportune time for reformers. What sort of reforms are being contemplated, what is really driving the changes, and who is leading the charge? For the moment, the answers are shrouded in mystery, and the huddled masses have no way of telling.

The tobacco wars go global

Smoking isn't good for you. Of course, there are a lot of things that aren't good for you, but we are starting to get more and more data about what habitual smoking does to the human body, both to the user and to bystanders, and it is not at all pretty. Although there are strong ethical arguments against the practice (including its contribution to health care costs for smokers and non-smokers alike), smoking would be impractical to outlaw outright. In developed countries, smoking is increasingly frowned upon socially and curtailed legally: it is getting more and more difficult to smoke in public space, smokers are regarded insurance risks, direct tobacco advertising pretty much a thing of the past, and only last week tobacco companies were required by the US Food and Drug Administration to put rather graphic warning labels on their cigarette packs. Not exactly a friendly business climate for marketing and sales.

Which is why developing countries have become so attractive for multinational cigarette companies over the last decade. The regulations -- for instance on tobacco advertising -- in some developing countries are less restrictive than those in the United States or Europe, and so companies search the world for regions marked by weak legislation and a strong consumer base, such as Indonesia. In this struggle between global big tobacco and global health agencies, the gloves are apparently off. Philip Morris has sued the country of Uruguay for loss of profits due to 'excessively restrictive' advertising policies. The World Health Organization, for its part, is advocating for stronger tobacco policies and laws globally, and encouraging individuals and governments to sue tobacco companies for harms to health. The WHO has even chosen to sponsor a summit in Uruguay this week, attended by representatives of over 170 nations, to analyze and support policies that reduce the prevalence of smoking on this planet.

The struggle against smoking that started in the United States and Europe is now to be played out around the globe, on very many fronts. A complicating factor in the debate is that tobacco is also grown in some developing countries (such as Malawi), and curtailing tobacco sales could in the short term have a negative impact (health and otherwise) on poor tobacco farmers, pickers and processors. These considerations are not without merit, but they are ultimately outweighed by the damage (long and short term) smoking causes, particularly in developing countries that do not have the health care systems to adequately cope with the effects tobacco has on its users.

The ethics of global trade in human flesh and bone

The Bulletin of the World Health Organization has an interesting article out in its November issue, entitled 'Human cells and tissues: the need for a global ethical framework.' The authors describe the technological advances and growing interest in the field of tissue transplantation, and predictably, the rise of private, profit-seeking companies engaged in the procurement, processing and sales of human tissues. The biggest tissue corporations with the most aggressive and questionable practices, from the looks of the article, appear to be American. Medical and public health uses are only one possibility among others. Private companies have an obvious bottom-line interest in trading tissues for expensive cosmetic purposes such as penis widening or lip enhancement, if not more mundane uses, such as those we normally associate with the flesh of horses or fish: paste, glue, powder and suspensions. As far as current practices of informed consent go, those who donate or trade tissue on behalf of family members may or may not know where the tissue ends up, with the unfortunate possibility that your skin from your Granny's forearm unknowingly ends up on some stranger's foreskin. In addition,

there is the usual ethical concern about flesh and bones from the poor being harvested for the bodies of the rich, similar to concerns about the organ trade, only here there are more body parts in stock: heart values, corneas, patellas, powdered bone, hip sockets, you name it.

The authors call for regulation of the global trade in human tissues through the development of a binding ethical framework from the World Health Organization. However, it is clear that their proposal would be labelled 'socialist' by corporate interests in the United States, seeing as the authors call for 'reasonable profits' to be channelled into improvements in quality, safety, accessibility and R&D, and they insist that the ethical framework should 'prohibit financial gain on the human body and its parts.' If formulated this way, the framework would join the list of international guidelines that the United States would not sign onto. Which might not be so bad, if the US was not already such a dominant player in the human flesh and bone market.